Anesthesia Coding Alert

Question: An established patient came to our office to discuss results of a previous procedure. Our physician and the patient spend the majority of the 30 minute visit discussing the patient's response to the diagnostic injection, available treatment options, risks, and benefits. What's the correct level of E/M service to report?

Washington Subscriber

Answer: The history and exam key components are more than likely minimal in your case, but since counseling and coordination of care dominate the encounter, you can use time as the controlling factor in assigning the E/M service level -- if you have the appropriate documentation.

If the supporting documentation includes both the total time of the visit and the amount of time spent in counseling and coordination of care and a brief summarization of the counseling, you may select the E/M code based on total visit time and report 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...), which specifies "physicians typically spend 25 minutes face-to-face with the patient and/or family." Counseling includes the physician discussing with the patient and/or family one or more of several areas including diagnostic results, prognosis, risks and benefits of management (treatment) options, or importance of compliance with chosen management (treatment) options, according to the E/M services guidelines outlined in CPT.